This is Lab Medicine Rounds, a curated podcast
for physicians, laboratory professionals and students.
I'm your host, Justin Kreiter,
a transfusion medicine pathologist
and assistant professor of laboratory medicine
and pathology at Mayo Clinic.
Today we're rounding with Dr.
Robert Fazio, assistant professor of radiology
and division chair
of breast Imaging at Mayo Clinic here in
Rochester, Minnesota.
Thanks for joining us today, Dr. Fazio.
Well, thanks so much Dr. Coyer.
This is, this is fantastic.
I've never been part of one of these before
and so I'm, I'm looking forward to it.
Oh, we're grateful for your time.
I think, you know, I, I kind of, this topic came up
because I remember fondly when I was in training
and learning about kind
of doing some breast needle diagnosis
and such, like just remembering
how important the conversation was with our radiologists.
And so I maybe if we could kick things off.
I'm kind of curious from your perspective
as a radiologist and,
and really a division chair of breast imaging,
why is it important, do you think, for pathologists
to understand a few fundamentals of breast imaging?
Well, sure, no, I think that's a, that's a great question.
Really kind of an open-ended question to get started,
and I'd be interested in your thoughts as well, you know,
after, after we talk through this a little bit.
But, you know, I think, I think that pathologists really,
who understand the basics
of our imaging really might be able
to arrive at their diagnoses faster and,
and with more confidence, you know, particularly
if the cases are challenging.
I think that both clinical
and imaging information really about certain cases can be
useful to narrow a differential diagnosis
or even provide a more confident diagnosis.
You know, you and I are really both in the fields of,
of turning shades of gray into black
and white answers, you know, for our clinical colleagues.
And I think imaging knowledge really can, can help you
make those diagnosis and, and,
and make that challenge happen.
I think, you know, ultimately our pathologist understanding
of, of imaging fundamentals can aid in kind
of the confidence of reporting
and also aid in concordance reporting,
which is essential for, for treatment planning,
particularly in cancer cases.
Wow. You know, that really resonates with me
because of Exactly, I, I think about the,
the, what's the adage?
The, the pot calling the kettle black.
Sometimes pathologists, we kind of, you know, put, you know,
great information in our comments
and sometimes our, our colleagues don't exactly read our,
our comments, just look at the, what we call the
above the line diagnosis and,
and we're saying like, oh, didn't you read our, our report?
And I imagine the same thing is, is true in, in radiology.
And so it's probably, yeah, that impetus
for having a little bit
of fundamental knowledge probably goes a long way.
Or sometimes we talk about when is it important
to pick up the phone and call.
Yeah, abso absolutely.
I really, I really actually enjoy reading the comments.
I, I know that when I see an extra comment, you know,
below the, the diagnosis, the official diagnosis,
I know that, you know, that's a case that
that maybe isn't as straightforward
and you guys are thinking about, you know, thinking out
of the box and doing some different things to make sure
that your diagnosis is correct.
Y you know, and if I might ask where, where along in,
in your, you know, training
and development, did you kind of come to that kind
of realization of, of kind of the comments and,
and the role that it's playing in the PATH report?
Sure. Prob I, I suspect probably in my fellowship is when,
when that sort of hit me a little bit, I think in residency,
you know, you're all just, you're just trying to get
through the rotations and do your best to, you know, to,
to pass the courses and, and, and pass your exams.
And in fellowship, you know, you really start
becoming part of the team, I think, and you contribute
and you provide those contributions.
And so, you know, that's where I kind of learned that,
that some of these comments might be
even more important than the actual above comment diagnosis.
Hmm. Wow. I think that's so important.
You know, thinking about our audience physicians,
laboratory professionals
and students, this kind of goes to what you're saying,
this kind of interprofessional understanding
what others on the team are, are doing
and how they're contributing.
Maybe we can dive into that a little bit.
You can kind of, you know, I'm curious,
what are a few aspects of breast imaging that, you know,
pathologists, it'd be, it'd be really helpful for them
to appreciate?
Oh, sure, sure. You know, I, I think,
I think there are a few things that are useful.
I, I think, I think it can be helpful for pathologists
to understand sort
of the imaging impression of what we sample.
And as this, I think can help narrow the differential in
challenging cases.
I, I think it's useful for you guys
to know if we're sampling, say, a mass lesion
or calcifications or architectural distortion
or whatnot, you know,
because each of these things have rather unique imaging
features and it can steer you down the right pathway when,
when you're having challenges as well.
I think it's useful for you guys to know our level
of suspicion and also which modality we're,
we're using for our imaging guidance.
And then finally, I think, I think it's useful for you
to know how we performed the biopsy.
You know, did we use a spring loaded device?
Did we use a vacuum assisted device
or did we perform an f n a, you know, for, for example,
you know, let's say I see suspicious calcifications on a
mammogram and we go on to biopsy those calcifications
with vacuum assistance
and get good samples, send calcifications.
And in our impression, you know,
we say high suspicion calcifications, suspect D C I S,
and you see D C I S I mean, that's a slam dunk, right?
That's easy. Probably don't need a comment,
comment Ab Absolutely.
Where those, where those things all, all align.
So I guess in the impression that's going
to be in the report, right,
like you're saying mass calcs architecture,
and you said also that level of suspicion, how,
how should we interpret or receive that level of suspicion?
Like is it, is that kind of a, a binary
or should we really try to see that as a,
as a, a shade of gray?
I'm kind of thinking about in our world of like cytology,
you know, there is kind of specific words
that are used in this kind of shade of, of gray
and how should we kind of interpret that?
Sure, sure. Well, usually when I send a clinical
impression, I'll indicate high intermediate
or low Suspicion and then whatever it is that I'm sampling.
And, and so I try to, I try
to make it a little bit black and white.
I don't give high or low, I just high intermediate or low.
If I'm pretty confident this is gonna be D C I S
for example, and,
and I say high suspicion calcifications
and you, you report back fibrocystic changes, then you
and I need to have a phone conversation probably.
And, and so I, I try to, I try
to make it a little bit black
and white for you guys as well.
Oh, that's helpful. And can you elaborate a little bit on
you, you mentioned that modality is for what type
of imaging is used
and how that might be helpful
for the pathologist to understand.
Can you kind of elaborate on what you mean by that?
'cause as an outsider, I'm not sure if I'm really kind
of picking up what you're talking about.
Oh, absolutely, absolutely.
So, you know, the common modalities
that we use are mammograms, ultrasound, and M R i.
Those are probably the top three.
And so if we're biopsying something with mammogram guidance,
and so that would be something like a stereotactic breast
biopsy or a tomosynthesis guided breast biopsy.
You know, you're, we're we're usually aiming at something
that could be D C I S or not.
Could it be invasive or microinvasive? Absolutely.
But, but when we're doing a, a stereotactic biopsy,
we're thinking about D C I S the most.
Whereas if we're using ultrasound
or m r I guidance, we're probably targeting a mass.
And so that could be invasive malignancy
or any of the benign masses that that,
that can be diagnosed in the breast.
And so that's sort of, that's sort of what I mean
by useful to know kind of the modality.
Ah, no, that, that's very helpful.
You know, we've been kind of playing around
with this idea of kind
of this interprofessional collaboration, like you said,
in certain situations, you know, we need
to have a phone call and, and talk things out.
You know, knowing that the, the audience here,
we have a lot of pathologists and
and lab medicine folks that are listening to this and,
and students along the pathway of hopefully playing this,
this team sport of medicine.
You know, what are your thoughts on
how pathologists could better collaborate with radiologists?
And I, I really ask this question 'cause sometimes
it's hard to know how do I get started collaborating
with an outside group?
And so, you know, your insights here are really appreciated.
Oh, absolutely. You know, first
and foremost, I really do think our collaboration efforts
are, are fantastic.
And particularly in the clinical arena,
we really are the only subspecialty that works
with the breast pathologists
that perform concordance reporting on our biopsy samples.
I don't think anybody else does that.
And so I, I think that our collaboration
between our groups really, really facilitates this,
the ability to do that.
Otherwise, you know, as you mentioned on the clinical side,
I think phone conversations are always helpful.
If you guys are con confused about the material
that we send, certainly happy to take a conversation
or if we can provide any additional, you know,
information about what you might be seeing
in a challenging case, happy, happy
to discuss it at any time.
You know, in addition, we're,
we're starting our radiology
patho pathology concordance conference backup.
This is a conference that we run each week.
Our fellows run it,
and we like to get as many people there
as possible from the multidisciplinary team,
but particularly radiologists and pathologists.
So to sort of discuss some
of the more challenging cases that we biopsied,
maybe the week previous covid really kind of hit
that conference hard
and we sort of, it just sort
of went away for about three years.
But, but our current fellows are really excited
to start it back up and we're, we're starting
to do those conferences again.
I, I still remember, you know, some very,
very eager pathology fellows that came to those conferences.
They, they even bring PowerPoints with slides about,
you know, the, the biopsy findings.
And it was really, really useful.
That was maybe four or five years ago,
but you know, that that conference was really beneficial
to our trainees and I think to your trainees as well.
And we'd love, we'd love for you guys to, to come
to those conferences again
and I'm, I'm happy to try to facilitate that.
Yeah, that's fantastic and great
for our audience to hear, right?
'cause we have a lot of audience outside of Mayo
and they might be kind of thinking about how,
how is this kind of play out in their own area?
Some may have these conferences that are going
or some might have some like ours where Covid kind
of gave us a little bit of a, a pause and a skip.
I'm kind of curious, you know, there's a lot,
because we have our, our student listeners,
I'd be curious to kind of just hear your thoughts on,
you know, how for these kind
of interprofessional conferences, right?
That's, that's where like I think you're highlighting
some important learning is happening for
how your radiology trainees are interacting
with pathology trainees, pathology consultants.
Are, are there any thoughts you've had over the years
for either, you know, how do you kind of prepare people
for going into these environments
or are there kind of some common feedbacks
that you've given to trainees over the years
to learn the most from these sorts of collaborations?
Yeah, I mean, I, I think, I think there's a lot
of good kind
of on the fly discussion at these meetings that
that can be beneficial to, to teach
the interdisciplinary team about the others fields.
You know, ideally we would have breast pathology fellows
rotate with us to visit our procedural practice as well.
I, I'm not sure if that's happening right now.
I think it has happened in the past.
We, we do send our fellows to you
and they're very, very complimentary of those weeks just
to see, you know, see
what they've biopsied under the microscope and,
and how that compares to, you know, all
of the other breast pathologies out there.
So rotating,
I think in the other subspecialty is really helpful.
Yeah, I think that's been wonderful.
As I've, you know, talking with our trainees over the years,
this idea that they understand kind of the workflow
with the other groups so they can understand
where sometimes various pressures come up
and certainly goes a long way for, you know, if, if you
and I have have met in, in real life and shared a laugh
or whatnot, like it, it makes it easier
to pick up the phone and have those,
those critical conversations.
Yeah. I also think it's really, really useful.
I mean, if there's an interesting case that, that they can,
you know, write up very quickly.
I mean, case reports can happen pretty fast
and you know, if you have a, a collaborative team on
that between two fellows
or two residents, I think those are fantastic opportunities.
Oh, absolutely.
And you know, I'm grateful that you're highlighting how
what might be originally perceived
as maybe a clinical practice arena thing,
a clinical domain,
how it's filling roles in both education as well
as the research shield.
I I think that's a true statement.
Can I maybe close with just kinda asking you, you know,
how might breast imaging change in the, in the coming years?
I think a lot of our audience aren't necessarily, you know,
don't, don't have your vantage point and perspectives
and, and curious what you see in the coming
years for breast imaging.
Sure, sure. I, I think it's an exciting time to be honest.
I, I think that there could be some changes in
how screening is performed.
You know, right now everybody gets an annual mammogram
starting at age 40 and you know,
going into their eighties and nineties
and every year they have to attend that mammogram.
And you know, we detect a lot of,
of tiny cancers on those mammograms now in the future,
and people are working on this right now,
but I think that there may be opportunities
for blood tests as initial screening tools.
Patients would get their annual blood test.
Those that are negative would be done for the rest
of the year until their next annual test.
Those that are positive would end up coming to us to,
to get diagnostic imaging rather than a screening mammogram.
The other thing I think could be exciting is
that there are a lot of developments in M R I right now
and abbreviated m r I might be the future
of screening as well.
It's much more sensitive and specific than mammography is.
The trouble with, with m r I really is
that the machines cost a lot.
You know, that the exams take a long time to perform.
Patients need to have an IV placed with contrast.
And so if we can get by some of those things
and make the examination shorter to perform, I think that's,
I think it has potential for sure.
I think AI will be a, a,
a factor in helping us provide diagnoses in the future.
We're still working to try to figure out the best way
to incorporate AI into our practice.
You're probably doing the same thing.
I really hope that imaging specificity will improve, which,
you know, would decrease really the need
for biopsies in many cases.
I've thought that this would happen for years
and so far it hasn't happened.
We do as many biopsies now as we have 10 years ago when,
when I started on staff.
A couple other things. I think,
I think image guided percutaneous therapies like
cryoablation has potential to reduce
open surgical treatment.
I think that has a, a future.
But, you know, having said, having said all that, I I,
I do think that image guided biopsies are not going
away anytime soon.
And so you and I will have many years
of collaboration ahead of us.
I think
I'm really looking forward to that and,
and I really appreciate it is really
quite an extensive list.
You're, you're sharing with our listeners,
which I I'm sure for that there's at least something
that's kind of planted in every listener's mind in
that list that you mentioned.
We've been rounding with Dr.
Fazio talking about fundamentals of breast imaging
and what pathologists need to know.
Thanks for joining us today, Dr. Fazio.
Absolutely. Dr. Corder, thanks so much for the invitation.
And to all our listeners, thank you for joining us today.
We invite you to share your thoughts
and suggestions via email
to MCL education@mayo.edu.
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We encourage you to continue to connect lab medicine
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